Clinical Services Intake Information

To register for diagnostic testing or tutoring, please complete the form below.

 

Parent/Guardian information
Last name	First name
Mailing address	City
State	Zip
Home phone number	Work phone number
E-mail address	Preferred contact?
	Select one home phone work phone e-mail
Student information
Last name	First name
Date of birth	Age
Grade	School
How did you hear about the Reading Center? (school, friend, website)
Provide a brief history of the student's reading and writing development and any of the problems he/she has encountered.
Type of service desired?
Testing Tutoring Both
If you are interested in tutoring services, check the preferred semester and time.
Select a semester Fall: Tuesday, 4:30-6 p.m. Winter: Tuesday, 4:30-6 p.m. Summer: Tuesday, Thursday July 7-30, 9:30-11:30